Vital Signs Obesity, diabetes and sedentary lifestyles may greatly influence a client s abilities during testing procedures in your Occupational Health Services. There has been an increase prevalence in questions regarding vital signs and cardiovascular endurance related to the FCE. The following is a review of physiologic responses and references to help establish your facility guidelines. Physical inactivity is a major risk factor for developing coronary artery disease. It also contributes to other risk factors, including obesity, high blood pressure, high triglycerides, a low level of HDL cholesterol and diabetes. 1 Heart disease has been the leading cause of death in the United States for the past 80 years and is the major cause of disability. 2 In 2005, 133 million people, almost half of all Americans live with at least one chronic condition. These account for 70% of all deaths in the USA and for more than 75% of the nation s $2 trillion medical care costs. 3 The data from 2005 reveals heart disease as the leader in deaths, accounted for 652,000 deaths in the United States. Obesity rates among adults have risen significantly and along with it the incidence of diabetes, cancer and heart diseases. In 2005 2006, data from the National Center for Health Statistics show that 34% of US adults 20 years of age and older (over 72 million people) are obese. 4 How does this relate to working with your clients? Before you begin a FCE, you evaluate your client for physical limitations by testing or observing gait, posture, balance, coordination, ROM, MMT and other relevant tests. Knowing the client s limitations provides information to keep the client safe in testing and correlate physical and functional limitations in the FCE. In addition to these observations physiologic response to the functional tests are monitored to assist in determining maximum effort. With an increase in activity or stress there is an increase demand for oxygen. The heart responds to this increased need by increasing the amount of blood the heart pumps out. It can do so by increasing blood pressure and/or increasing heart rate. If that is not what you see during testing, it is important to consider whether the client is not giving maximum effort by considering all the observation criteria for testing or whether the client s physiologic response is being influenced by medications or other regulatory responses. The heart rate and blood pressure is regulated by the autonomic nervous system. The sympathetic division increases heart rate through a network of nerves called the sympathetic plexus. It also influences heart rate and blood pressure by releasing hormones into the blood stream (epinephrine and norepinephrine). The parasympathetic division of the autonomic nervous system decreases heart rate through the vagus nerve. Heart rhythm is considered abnormal only when the heart rate is inappropriately fast (tachycardia), slow (bradycardia) or irregular or when electrical impulses travel along abnormal pathways. 5 The most common cause of arrhythmias is a heart disorder, particularly coronary artery disease, heart valve disorders, and heart failure. 5 However, medications (prescription or over the counter) and other factors may lead to arrhythmias affecting a client s heart rate response. Medications that affect heart rate and blood pressure include beta blockers, antihypertensive drugs, calcium channel blockers, diuretics, adrenergic blockers, ACE inhibitors to name a few. An increase in heart rate may occur with emotional stress, increase in activity or exercise, excessive use of alcohol, increase in salt intake to name a few contribution factors. A decrease in heart rate may occur secondary to pain, fatigue, loss of fluids
(dehydration, diarrhea, vomiting) and other factors. When the heart's ability to deliver blood is impaired it may result in weakness, SOB, dizziness or fainting. Many people are not aware of abnormal heart rates or blood pressure, but they may experience the symptoms. Heart Rate (American Heart Association 1 ) Information relating to target heart rate for training purposes. To calculate your target training heart rate, you need to know your resting heart rate. Resting heart rate is the number of times your heart beats per minute when it's at rest. The best time to find your resting heart rate is in the morning after a good night s sleep and before you get out of bed. The average resting heart rate is 60 80 beats per minute. However, for people who are physically fit, it s generally lower. Also, resting heart rate usually rises with age. Once you know your resting heart rate, you can then determine your target training heart rate. Target heart rates let you measure your initial fitness level and monitor your progress in a fitness program. You do this by measuring your pulse periodically as you exercise and staying within 50 to 85 percent of your maximum heart rate. This range is called your target heart rate. The table below shows estimated target heart rates for different ages. Your maximum heart rate is about 220 minus your age. The figures below are averages, so use them as general guidelines. Age Target HR Zone 50 85 % Average Maximum Heart Rate 100 % 20 years 100 170 beats per minute 200 beats per minute 25 years 98 166 beats per minute 195 beats per minute 30 years 95 162 beats per minute 190 beats per minute 35 years 93 157 beats per minute 185 beats per minute 40 years 90 153 beats per minute 180 beats per minute 45 years 88 149 beats per minute 175 beats per minute 50 years 85 145 beats per minute 170 beats per minute 55 years 83 140 beats per minute 165 beats per minute 60 years 80 136 beats per minute 160 beats per minute 65 years 78 132 beats per minute 155 beats per minute 70 years 75 128 beats per minute 150 beats per minute Important Note: A few high blood pressure medications lower the maximum heart rate and thus the target zone rate. If you're taking such medicine, call your physician to find out if you need to use a lower target heart rate.
Blood pressure classifications for adults are as follows: 6 Category Systolic BP (mm/hg) Diastolic BP (mm/hg) Normal Below 120 Below 80 Prehypertensive 120 139 80 89 Stage 1 hypertension 140 159 90 99 Stage 2 hypertension Above 160 Above 100 Directions for use of sphygmomanometer 11 : Blood pressure should be taken after a person has sat for 5 minutes. When the sphygmomanometer is used, the client should sit with legs uncrossed and back supported. The arm should be bare to prevent constriction from clothing. The arm should be slightly flexed and relaxed with the forearm supported on a table so that the arm is about the same level as the heart. The cuff is wrapped around the arm with the lower end of the cuff being about one inch above the antecubital space. The rubber bag should be over the brachial artery. If the cuff is too small your BP reading may be too high, if too large it may be too low. Use an appropriate size for your client. The stethoscope should be applied directly over the brachial artery. Pressure is then increased in the sphygmomanometer quickly and released slowly so each heartbeat can be heard. Once the systolic pressure has been determined continue deflating the system at a rate of 2 to 3 mmhg per heartbeat. The sounds change in intensity and quality becoming dull and muffled quite suddenly and then finally cease. The point of cessation is the best index of diastolic pressure. Results depend upon proper fit, proper procedure in testing and maintenance of the equipment. FCE testing and documentation requirements: Evaluation, observations and monitoring of heart rate and blood pressure are physiologic responses that are included in your FCE testing procedures. FCE documentation and process should include: 1. That the client did not have contraindications to testing. This includes a review of the Yes answers in the PAR Q with the client. 2. The client s medical history. Those with a history of cardiovascular disease, thyroid disease, kidney disease, diabetes or taking medications that affect HR may require additional monitoring of BP during testing. 3. Heart Rate is monitored throughout the testing. 4. Documentation if cardiovascular endurance caused modifications in the testing such as repeated needed resting periods to reduce BP or HR. Symptoms of SOB, dizziness, nausea or fainting should also be reported. Establishing Guidelines: If you work in a large institution that has established HR and BP guidelines it makes sense to keep your FCE guidelines consistent. If you do not have current guidelines, you might discuss this with your medical director or a cardiac physician. Your primary responsibility in FCE testing is to provide a safe comprehensive evaluation and determine the client s physical and functional abilities and limitations. There are so many variables with individual s medical history, medications, physical exam that your skills as a therapist are essential for making sound clinical decisions during the FCE. Although a heart rate monitor is used through out FCE testing, there are variables that may affect heart rate. If a client s vital signs exceed guidelines, provide for a rest period, take the heart rate or blood pressure again and determine if it is safe to continue testing.
Resources for Guidelines Heart Rate: 7, 12 To determine the client s maximum heart rate (220 age = Max. HR.) The upper limit during exercise varies depending upon the source you use and commonly will range from 60 to 94% of maximum heart rate. If a client s heart rate exceeds guidelines allow the client time to rest and determine if it returns to below your established upper limit. AHA guidelines have an upper limit of 85%. 1 Mayo Clinic guidelines for upper limit is 85%. 7 The Cleveland Clinic guidelines for maximum heart rate is 85% of maximum HR. 12 The American College of Sports Medicine recommends intensity levels for exercise between 64 and 70% and maximum heart rate of 94%. However, for apparently health individuals, the range is often narrowed to 70 to 85% of max. HR. 10 Blood Pressure:Here are several resources to assist in establishing a guideline for blood pressure in your clinic. The American College of Sports Medicine provides guidelines for safe blood pressure during exercise as follows: Age Group BP Guideline Age 65 or older No greater than 150/90 Age 50 65 No greater than 160/100 Below age 55 Seek medical clearance if higher than 160/100 The following table is from Therapeutic Advances in Cardiovascular Disease. 8 The conclusion acknowledges the importance of endurance and resistance exercise and that with guidance and supervision even the moderate to high risk cardiac patient can benefit from exercise regimes. The table refers to contraindications for resistance training. Contraindications to Resistance Training Absolute Contraindication Unstable CHD Decompensated heart failures Severe pulmonary HTN (mean arterial pulmonary pressure 55 mmhg) Uncontrolled arrhythmias Uncontrolled HTN ( 180/110 mmhg) Marfan s syndrome Severe symptomatic aortic stenosis, aortic dissection Acute myocarditis, pericarditis or endocarditis Relative Contraindication Major risk factors for CHD Diabetes Hypertension above 160/100 mmhgmusculoskeletal problems Patient with pacemaker or defibrillator US Department of Transportation. Federal Motor Carrier Safety Administration. Medical Advisory Criteria for Evaluation Under 49CFRPart391.41 9 A blood pressure at or greater than 180 (systolic) and 110 (diastolic) is considered Stage 3, high risk for an acute BP related event. The driver may not be qualified, even temporarily, until reduced to equal to or less than 140/90 and treatment is well tolerated. The driver may be certified for 6 months and biannually (every 6 months) thereafter if at recheck BP is equal to or less than 140/90.
Summary: Establish your facility guidelines for Heart Rate and Blood Pressure during FCE testing. Include rest time requirements for retesting if the client has exceeded guidelines. Your FCE V.2 manual describes the facility policies and procedures that should be established in your facility (page 27 29). The primary goal is to keep your client safe while testing. The client should be wearing a heart rate monitor during testing. Depending upon the client s medical history and your findings you may need to contact the client s physician for medical clearance prior to testing or you may need to eliminate certain test items secondary to restrictions or the client s physiologic responses. Your experience, training and judgment as a clinician is crucial to the overall process of performing an FCE. REFERENCES: 1. American Heart Association. Target Heart Rates. www.americanheart.org 2. Prevalence of Heart Disease United States, 2005. The Journal of the American Medical Association. 2007; Vol. 297 No. 12: 1308 1309; March 28, 2007 3. Chronic Disease Prevention and Health Promotion. CDC, Department of Health and Human Services. www.cdc.gov/nccdphp/overview.htm 4. Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity. CDC, Department of Health and Human Services. Revised August 2008. 5. Introduction: Abnormal Heart Rhythms: Merck Manual Second Home Edition. January 2008 with last full review/revision by L. Brent Mitchell, MD. www.merck.com 6. High blood pressure (hypertension). www.mayoclinic.com/health/blood pressure/hi00043 7. Diane Dahm, M.D., Jay Smith, M.D. Fitness for everybody. Your guide to a life of fitness and health. Mayo Clinic, Rochester, MN. First edition. 2005 Mayo Foundation for Medical Education and Research. 8. Meka, Naga, Katragadda, Srikanth, Cherian, Biju, Arora, Rohit. Endurance Exercise and Resistance Training in Cardiovascular Disease. Therapeutic Advances in Cardiovascular Disease. 06/10/2008. www.medscape.com/viewarticle/572722_print 9. US Department of Transportation. Federal Motor Carrier Safety Administration. Medical Advisory Criteria for Evaluation Under 49CFRPart391.41 http://www.fmcsa.dot.gov/rulesregulations/administration/medical.htm 10. ACSM s Resources for Personal Trainer. www.acsm.org Chapter 18 Cardiopulmonary Training Program p.415. 11. High Blood Pressure: Heart and Blood Vessel Disorders: Merck Manual Home Edition. April 2007. Last full review/revision by George L Bakris, MD. 12. Cleveland Clinic Miller Family Heart and Vascualr Institute. Heart and Vascular Health and Prevention. Pulse and Target Heart Rate. http://my.clevelandclinic.org/heart/prevention/exercise